t he a lo pecias (a) (b) (c) (d) Figure 13.10 (a,c) Pre-op and (b,d) post-op 2 years 9 months; 4483 grafts were transplanted in one session. 138 manage ment o f d ef init ive h a ir a l opecia i n a sia ns MatriStem has also been used with no current scientific ethnic backgrounds, a thorough diagnostic investigation proof that it has worked in reducing donor scarring and has to be done to ascertain if the cause of hair loss is ame- increasing hair growth. I have no personal experience nable to hair transplantation. Medical therapy alone may using these products and awaits the results of further be the treatment option of choice for many etiologies (e.g., studies. telogen effluvium, alopecia areata, active cicatricial alo- For graft storage, the majority of surgeons use NSS, pecia, etc.). However, for certain causes of hair loss, such Ringer lactate, or Plasmalyte. We have studied with as female pattern hair loss (FPHL), transplantation may patient permission on one patient, William E medium be a consideration. After confirming that the hair loss used as storage solution on the right side and normal etiology is amenable to hair transplantation, evaluation saline on the left side for comparison of growth rates then has to be made as to whether the female patient is a and different times of insertion. Grafts were stored half good candidate for this procedure. In some female cases, in NSS and the other half in William E medium for 2, 4, the donor hair might not be sufficient to cover the hair 6, 24, and 72 hours and then planted accordingly. After loss at the recipient area. The Ludwig and Norwood types 6 and 10 months there were amazing results with good of pattern baldness seen in women are the most common growth on William E solution compared with less growth conditions for which surgeries are performed. in NSS (presented at ISHRS Annual Scientific Meeting at Hair characteristics of Asian women are similar to Bahamas in 2012) (Figure 13.11). those of Asian men, except in women there is more sub- cutaneous fat, and the skin is soft nd easy to cut. Correction of female pattern baldness in Asians Through the years, there has been a steady increase in Approach to hair transplantation in Asian women Asian women seeking consultation for hair loss due to In Ludwig type baldness, the main problem is central various causes and subsequently undergoing hair trans- thinning with retention of the frontal hair line; thus, the plantation as a treatment option. As with women of all goal would be to add density over the thinning area in the (a) (b) (c) (d) Figure 13.11 (a) Before and (b) immediately after surgery. (c) Six months post-op with the left half of grafts stored in NSS and the right half stored in William E medium. (d) Eight months post-op. 139 t he a lo pecias central aspect of the scalp. If the area to be transplanted correct complications if they occur. There are significant has existing hair, minimizing damage to these follicles is differences between Asian skin and the skin of other paramount. Adjacent hair follicle injury can be lessened ethnicities. Even within the Asian race, significant dif- by following the angle and direction of the existing hair ferences are apparent. In the Indian population the skin and using high-power loupes of at least 3.5 when mak- varies significantly in terms of skin color, which makes ing the incisions.24,25 If the patient has preexisting hair, pigmentation an important scar issue. 20–25 graft/cm2 may be appropriated. Telogen effluvium Early complications include facial swelling, which is or post-op shedding may cause distress to the patient. the most common seen in hair practice; however, with the This must be informed, recorded, and signed. Minoxidil addition of a steroid to the tumescent fluid, wearing of lotion might be helpful if the patient uses it preoperatively the headband, plus a cold compress to the forehead post- at least a few months prior to surgery. op, the incidence is dramatically improved.21 If persistent In Norwood–Hamilton pattern (Figures 13.12 and hiccoughs occur during surgery, this can limit the abil- 13.13), hair loss is usually confined to the frontotemporal ity to place the grafts. Bleeding, syncope, and infection region. High forehead, deep temple recession with min- are uncommonly seen. Post-op effluvium at recipient and iaturized hair at the gulf are more common findings in donor sites are unpredictable; patients need to be warned women. The goal is to restore the frontotemporal hairline. that it may occur. Hair line design is time consuming in women. Pattern Late complications are scarring, pitting, effluvium, and design that is oval and heart shaped, with or without a poor direction and angle (Figure 13.14). Ridging and tent- widow’s peak is drawn, and then the patient participates ing are still seen in the hair practice today. Inadequate and in observing whether the new hair line fi s her face well. poor growth is of concern to the patient as well as to the sur- Because most patients have good and sufficient donor geon, and requires further investigation and assessment. hair, high density can be achieved with 40 or even 50 The difference between Asian and Caucasian surgery graft/cm in selected patients. results is mostly with the donor scar; again, the wider the The surgical technique in women is the same as in men. strip, the wider is the scar. Surgeons need to avoid tension upon closure. The scar is seen more in the younger age Complications in hair restoration in Asians groups and less in elderly patients. The surgeon needs to Surgical complications can happen even in experienced check for Ehlers–Danlos type II which can result in a very hands, and surgeons need to know how to avoid and wide scar. In case of a hypertrophic scar or keloid, a series (a) (b) Figure 13.12 (a) Before and (b) 8 months after 3030 grafts in Ludwig II. 140 manage ment o f d ef init ive h a ir a l opecia i n a sia ns (a) (b) (c) (d) Figure 13.13 (a,c) Before and (b,d) 1 year after 2419 grafts in Norwood type of pattern baldness. 141 t he a lo pecias (a) Figure 13.15 Wide and hypertrophic scar from strip (b) surgery after multiple sessions. Folliculitis Folliculitis is the most common complication occur- ring in practice, usually occurring about 3 weeks to 4 months postsurgery. It usually disappears spontaneously, but occasionally, a chronic recurrent form of folliculitis can develop. This may be due to a foreign body reaction of recipient dermis against the epidermal component of the transplanted hair or a small fragment of hair, as well as obstruction of a sebaceous gland, because no hair grafts have yet exited the scalp. Fortunately, this eventu- ally clears with time and rarely reduces eventual growth, although it can be delayed. Treatment consists of wet Figure 13.14 (a) Poor hair transplant direction and warm compresses for 15 minutes every 4–6 hours and angle; grafts were transplanted in posterior direction. wiping the area with alcohol 70%. Advise use of antiseptic (b) Poor growth. shampoo (Hibiscrub) twice a day, oral and topical antibi- otics, and drainage of pustules if necessary (Figure 13.16). Culture of the pustule for both aerobe and anaerobe plus of injections of intralesional corticosteroids (e.g., triam- Gram stain is helpful so the surgeon can give the appro- cinolone acetonide 10–40 mg/mL) are helpful to reduce priate antibiotic. the size or related symptoms. On average, three injections spaced at 4 and 8 weeks will markedly improve the scar. Scar revision is usually unsuccessful (Figure 13.15). I have done a few W-plasty procedures with only one acceptable result, the others having no change. The FUE planting into the scar may be helpful. Micropigmentation into the scar may be considered. Effluvium or postoperative shock loss of existing hair might not grow back at the recipient site, especially the miniaturized hair. The effluvium at the donor area will grow back after 4 months. There is no treatment for efflu- vium other than to be patient. Ingrown hair is uncom- monly seen and needs to be removed. Because there is a constant influx of newcomers enter- ing the field of hair restoration, pitting is still commonly seen in hair practice today, sometimes in conjunction with poor hair direction and angle that can be difficult to correct. The best solution may be to selectively surgically Figure 13.16 Post-op folliculitis drains with 21G despite punch out the most visible grafts. no pustule visible on the skin. 142 manage ment o f d ef init ive h a ir a l opecia i n a sia ns As a means of prevention of folliculitis, preoperative destruction of the hair follicle and irreversible hair cleansing of the scalp with shampoo reduces the colony loss. It is classified into primary (the hair follicle is the counts in the skin, resulting in less overall risk of infec- main target) and secondary (nonfollicular) disease. tion. Antiseptic shampoo pre-op is still debated because Dermatological disorders causing permanent hair loss it also kills resident flora on the scalp to fight against such as cicatricial alopecia make immediate diagnosis bacterial intruders. The use of systemic antibiotics is still and therapeutic intervention imperative. Location of controversial because the scalp contains an abundant biopsy is very important; it should include good hair at blood supply except in patients who have artificial heart the border of the lesion and inside the lesion that con- valves or prostheses.